Healthcare Provider Details

I. General information

NPI: 1861065831
Provider Name (Legal Business Name): KHA HOANG MA61112149
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 E YELM AVE STE C101
YELM WA
98597-8328
US

IV. Provider business mailing address

2405 SYCAMORE ST SE
LACEY WA
98503-3338
US

V. Phone/Fax

Practice location:
  • Phone: 360-458-7533
  • Fax:
Mailing address:
  • Phone: 360-878-5726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA61112149
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: